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AIM Benefits of mothers' own milk (MOM) for premature and sick neonates are well documented. To increase access, many neonatal units have a lactation consultant (LC) on staff. This study aimed to assess the impact of a permanent LC on (i) maternal access to LC support; (ii) staff confidence in providing Breast Feeding (BF) education and (iii) provision of MOM. METHODS Study included a staff survey and chart audit. Questions provided feedback on access to lactation support and meeting maternal needs. Audit data included: gestational age, birthweight, intention to breastfeed, documentation of LC appointment, provision of MOM at 12 hours, days 3, 7, 28 and discharge. Student's t-tests were used for numerical data and chi-squared tests for categorical variables. RESULTS Ninety-one staff surveys were returned, (pre 35/75 (47%), post 56/85 (66%) with staff reporting organising an LC appointment was significantly easier (P

Absconding from inpatient psychiatric care is a complex problem with significant and broad ranging effects for patients, staff, family/carers, and the broader community. Absconding includes leaving the ward without permission and failing to return from leave at an agreed time. This study is a retrospective chart audit of a data set of absconding events from 11 psychiatric wards in a metropolitan Australian city. The data set included both quantitative and qualitative data. The focus of this study is analysis of the qualitative data documenting what happened during events, with quantitative data provided to contextualize the qualitative analysis. A total of 995 absconding events by 488 patients were reported between January 2016 and June 2018, representing a rate of 1.6 per 100 admissions. Two themes were identified in the qualitative analysis. 'Having things to do' encompassed opportunistic absconding and volitional absconding. 'Something changed' represented predisposing events that affected the absconding behaviour, such as being stepped down in care (moving from a more acute to a less acute psychiatric unit), receiving bad news, or interpersonal conflict either between patients or between nursing staff and patients. Results highlight the importance of harm minimization strategies to reduce the incidence of absconding.

Background:The clinical profile of Aboriginal and Torres Strait Islander adults admitted to hospital with neurological injury is not well documented. Understanding these profiles may enable health professionals to provide more culturally responsive health care for this patient group. This study aimed to report the clinical profile of Aboriginal and Torres Strait Islander adults admitted to a regional Queensland hospital due to stroke or traumatic brain injury (TBI).Method:A 2-year retrospective medical record review of Aboriginal and Torres Strait Islander adults (≥18 years) admitted to a regional Queensland hospital with principal diagnoses of stroke or TBI.Results:There were 132 Aboriginal and Torres Strait Islander adult stroke (51.5%) or TBI (48.5%) admissions. The mean ages were 56.7 years for stroke and 42.7 years for TBI. The majority of patients (83.3%) were of Aboriginal descent with others identifying as Torres Strait Islander only, or both Aboriginal and Torres Strait Islander. Patients were from 26 diverse home locations across northern Australia, primarily Outer Regional or Remote/Very Remote geographical locations. All patients’ language backgrounds were documented as English only. Over 90% of stroke and 50% of TBI patients presented with medical co-morbidities.Conclusions:Patients had diverse geographical locations and cultural backgrounds, with many likely impacted by dislocation from home and country, as well as potential delays in receiving treatment. Despite this diversity, English was documented in patients’ medical records as their only language. The majority of patients also presented with multiple medical co-morbidities. Health professionals should consider these factors to ensure patients receive optimum and culturally responsive health care.

New multiple agency recommendations have encouraged the early introduction of peanut protein (PP) in high-risk children to decrease peanut allergies. However, many providers are hesitant to use these recommendations. Our objective was to increase the recommendation of new guidelines by providers during routine infant care and evaluate caregiver acceptance of early PP introduction.This QI project focused on changing providers' knowledge and attitudes as a means to change practice using the "Plan-Do-Study-Act" model. Following provider educational sessions in 4 clinical sites providers and caregivers were questioned about instruction on the introduction of PP. Pre and post educational intervention data were collected from providers using chart audit and caregivers' report through the modified Promoting Healthy Development Survey (PHDS).The educational intervention was effective in increasing provider knowledge (p .05), providers' dissemination of knowledge to caregivers through provider report (p .001) and caregiver report (p .05).Education increased providers' knowledge about the safety and importance of early introductions of PP, and allayed fears about initiating an allergic reaction. The increased provider recommendation to caregivers was validated by both provider and caregiver report. Caregivers felt comfortable initiating peanut protein.Provider education led to increased recommendation to caregivers on early introduction of PP and increased caregiver comfort introducing PP.

The prevalence of security guards in health care settings is growing worldwide. There is a need to explore and understand their role and actions to inform policy and training and support least restrictive practices in health care. The aim of this study was to conduct a retrospective chart audit of security guard logs to investigate security guard involvement in Code Blacks, called in emergency situations of personal threats including patient and/or visitor violence, in medical and surgical wards in a large metropolitan health network in South Australia. Security guards attended 1664 Code Blacks (0.63% of admissions) over the 2.5-year study period. Events were more frequently reported in medical than surgical wards. The most common reasons for security guard attendance were patients threatening/harming staff and patients threatening/harming themselves. The most frequent security guard actions were "Attend only/standby," "Physical restraint," and "Patient located and returned to the ward." The most frequent outcomes were physical restraint, chemical restraint, and de-escalation respectively. Results highlight the imperative that health services maintain and increase efforts to support least restrictive practice through policy directives and staff training.

BACKGROUND Clozapine is the most effective in treatment-resistant schizophrenia. Neutropenia is an adverse effect of the drug requiring treatment discontinuation. This study related treatment continuation with little or no interruption after a neutropenia episode. The study contrasted from rechallenge studies after an extended treatment interruption. METHODS This retrospective chart audit examined 37 patients with an episode of neutropenia. It described characteristics of patients continuing treatment with minimal interruption. FINDINGS Thirty-one patients continued treatment after an initial treatment interruption for less than 3 days. A probable cause for neutropenia other than clozapine was identified in 14 patients. Twelve patients continued treatment with a change in the absolute neutrophil counts threshold to 1000/μL to determine treatment cessation. Most patients recovered from the index episode of neutropenia within 2 days. They also frequently presented with recurring benign episodes of low neutrophil cell counts during treatment than a comparative group. IMPLICATIONS The study recommends modifying clozapine treatment protocol absolute neutrophil count thresholds to less than 1000/μL to determine treatment cessation. Consideration of other probable causes for neutropenia, diurnal variations in cell counts, and laboratory errors reduced preemptive discontinuation of treatment. A risk-benefit approach supports continuing clozapine treatment after an episode of neutropenia.

A pre- post-chart audits of 50 asthmatics assessed provider documentation for asthma classification and treatment according to national guidelines. Once baseline electronic medical records (EMR) audit was conducted the healthcare providers and clinic staff received training on the use of asthma diagnosis and treatment national guidelines. A post-training EMR chart audit (3-months after the training) was conducted for a pre-post-training comparison.

To improve nurses' comfort in helping laboring woman void on a bedpan after initiation of epidural analgesia, to increase the frequency of bedpan use in the labor and birth unit, and to decrease the use of continuous indwelling Foley catheters during the intrapartum period.Quality improvement project.A single large, midwestern U.S. hospital (3,000 births annually), where bedpans are infrequently used after epidural placement.Registered nurses on a labor and birth unit.A 20-minute educational presentation that included current urinary catheter evidence-based practice, preferential use of bedpans, and methods to help women void successfully was taught to all registered nurses in the author's labor unit. Nurses rated on a scale of 0 (not comfortable at all) to 10 (extremely comfortable) their comfort level at helping a woman with a bedpan. Primary data were collected through a convenience sample of anonymous surveys (n = 52) completed by registered nurses regarding their experience with bedpan and catheter use during labor and their comfort level helping women be successful with voiding. This was followed by a retrospective chart audit for women with term, singleton pregnancies who labored with epidural analgesia.Nurses' comfort levels increased from an average of 5.7 to 7.2 (p = .067). Postepidural bedpan use increased from 5.5% (n = 12) to 19% overall (n = 20; p .001), with five women using bedpans exclusively. When assisted with bedpan use, 38% (n = 12) of women were able to void 34 of the 53 times it was offered (64%). Use of continuous indwelling Foley catheters decreased from 61.7% (n = 137) to 54.7% (n = 58), and use of intermittent catheterization increased from 30.6% (n = 68) to 37.7% (n = 40).When assisted by nurses educated in and comfortable with different voiding techniques, women may be able to avoid medically unnecessary use of urinary catheters during labor.

Objective: To examine the impact of a clinical toxicology service on toxicology patients admitted to an intensive care departmentMethods: The authors performed a retrospective chart audit of all pa...

Introduction The development of effective interventions in hand and upper extremity rehabilitation is critically important; yet even the most promising interventions may not successfully be implemented in practice. Occupational and physical therapists who provide specialized hand and upper extremity rehabilitation services (“hand therapists”) can face extensive, multi-level barriers when attempting to use research findings in real-world settings, widening the long-standing research-to-practice gap. Concepts from the field of implementation science can be leveraged to address this gap and expedite the application of research discoveries that can maximize treatment outcomes of the musculoskeletal upper extremity client. As the intersection of hand and upper extremity rehabilitation and implementation science draws growing attention, there is a great need for researchers and clinicians to infuse implementation science into the hand and upper extremity rehabilitation research and practice contexts. Purpose The purpose of this article is to define implementation science and synthesize several studies from the hand and upper extremity rehabilitation field that have examined the effect of implementation strategies (eg, chart audit and feedback techniques; implementation teams) on implementation outcomes (eg, acceptability, fidelity). We also present recommendations for how (1) hand and upper extremity rehabilitation researchers can design studies to examine both patient outcomes and implementation outcomes relative to interventions for the musculoskeletal upper extremity and (2) hand and upper extremity rehabilitation specialists and administrators can develop implementation teams to facilitate the use of evidence in practice. Conclusion Collaboration between researchers and clinicians has great potential to advance the entirety of the hand and upper extremity rehabilitation profession, especially when such collaborations are guided by the implementation science field.

We conducted a chart audit of all patients attending an inner-city COVID-19 testing centre in Toronto, Canada between March and April 2020. Of the 2050 unique individuals tested, 214 (10.4%) were homeless. People experiencing homelessness were more likely to test positive for COVID-19 compared to those not experiencing homelessness even after adjustment for age, sex, and the presence of any medical co-morbidity (15.4% vs. 6.7%, p

BackgroundIt is unclear what the best strategy is for detecting COVID-19 among homeless shelter residents and what individual factors are associated with positivity.MethodsWe conducted a retrospective chart audit obtaining repeated cross-sectional data from outreach testing done at homeless shelters between April 1st and July 31st, 2020 in Toronto, Canada. We compared the positivity rate for shelters tested because of an outbreak (at least one known case) versus surveillance (no known cases). A patient-level analysis examined differences in demographic, health, and behavioural characteristics of residents who did and did not test positive for COVID-19.FindingsOne thousand nasopharyngeal swabs were done on 872 unique residents at 20 shelter locations. Among the 504 tests done in outbreak settings, 69 (14%) were positive and 1 (0.2%) was indeterminate. Among the 496 tests done for surveillance, 11 (2%) were positive and none were indeterminate. Shelter residents who tested positive were significantly less likely to have a health insurance card (54% vs 72%, p=0.03) or have visited another shelter in the last 14 days (0% vs 18%, pInterpretationOur findings support testing of asymptomatic shelter residents for COVID-19 when a positive case is identified at the same shelter but suggest limited utility of testing all shelter residents in the absence of a known case. Visiting another shelter in the last 14 days is associated with a decreased risk of COVID-19 positivity.

Background:An examination of invasive procedure cancellations found that the lack of pre-procedural oral screening was a preventable cause, for children with congenital heart disease. The purpose of this study was to implement an oral screening tool within the paediatric cardiology clinic, with referral to paediatric dental providers for positive screens. The target population were children aged ≥6 months to Methods:The quality implementation framework method was used for this study design. The multi-modal intervention included education, audit and feedback, screening guidelines, environmental support, and interdisciplinary collaboration. Baseline rates for oral screenings were determined by retrospective chart audit from January 2018 to January 2019 (n = 211). Provider adherence to the oral screening tool was the outcome measure. Positive oral screens, resulting in referral to the paediatric dental clinic, were measured as a secondary outcome. Provider adherence rates were used as a process measure.Results:Data collected over 14 weeks showed a 29% increase in documentation of oral screenings prior to referral, as compared to the retrospective chart audit. During the study period, 13% of completed screenings were positive (n = 5). Provider compliance for the period was averaged at 70% adherence.Conclusion:A substantial increase in pre-procedural oral screenings by paediatric cardiologists was achieved using the quality implementation framework and targeted interventions.

INTRODUCTION Specialists in a Maintenance of Certification program are required to participate in assessment activities, such as chart audit, simulation, knowledge assessment, and multisource feedback. This study examined data from five different specialties to identify variation in participation in assessment activities, examine differences in the learning stimulated by assessment, assess the frequency and type of planned changes, and assess the association between learning, discussion, and planned changes. METHODS E-portfolio data were categorized and analyzed descriptively. Chi-squared tests examined associations. RESULTS A total of 2854 anatomical pathologists, cardiologists, gastroenterologists, ophthalmologists, and orthopedic surgeons provided data about 6063 assessment activities. Although there were differences in the role that learning played by discipline and assessment type, the most common activities documented across all specialties were self-assessment programs (n = 2122), feedback on teaching (n = 1078), personal practice assessments which the physician did themselves (n = 751), annual reviews (n = 682), and reviews by third parties (n = 661). Learning occurred for 93% of the activities and was associated with change. For 2126 activities, there were planned changes. Activities in which there was a discussion with a peer or supervisor were more likely to result in a change. CONCLUSIONS AND DISCUSSION Although specialists engaged in many types of assessment activities to meet the Maintenance of Certification program requirements, there was variability in how assessment stimulated learning and planned changes. It seems that peer discussion may be an important component in fostering practice change and forming plans for improvement which bears further study.

Objective To better understand the impact of alcohol consumption on the clinical management of chronic diseases in a regional general practice setting. Methods A retrospective chart audit was undertaken of individual patient records at two large group general practices in Townsville, a regional Australian city. Three common indicator chronic diseases were selected that have clear management guidelines for general practice: type 2 diabetes; chronic obstructive pulmonary disease; and chronic kidney disease. The audits were analysed using SPSS software to examine the association between alcohol consumption on acquisition of clinical management targets and primary disease intermediate outcomes (haemoglobin A1c fraction; per cent of normal forced expiratory volume at one second; and estimated glomerular filtration rate). Results A total of 457 records were audited. Higher‐risk alcohol consumption is associated with reduced ability of patients to reach management targets (F[3,453]=3.68; p=0.012) and decreased standardised primary disease outcome (F[3,403]=2.86; p=0.037). Conclusion Higher‐risk alcohol consumption is associated with reduced attainment of chronic disease management targets and worse chronic disease outcomes. Implications for public health Alcohol consumption should be assessed frequently in people with chronic disease, especially when there is difficulty acquiring management targets or worsening of disease outcomes without a clear explanation. Better education about the potential associations between alcohol use and chronic disease would benefit those managing these complex conditions, both clinicians and patients.

Objective: To move closer to achieving the third target of the UNAIDS 90-90-90 goals, we prospectively implemented a viral load (VL) champion (VLC) program aimed at enhancing VL monitoring and recognition of treatment failure. Design: Three clinics in eThekwini, Kwa-Zulu Natal (low-, medium- and high-volume, encompassing 9184 patients overall) were each assigned a VLC. We employed a descriptive analysis (chart audit) to compare the pre-intervention period to a 1-year post-intervention period. The number of patients with a VL test performed 6 and 12 months after the intervention was calculated as a proportion of VL tests due at those time points (VL completion rate). Results: The pre-implementation VL completion rate at the three sites was respectively 68% (140/205 patients), 54% (84/155 patients) and 64% (323/504 patients), and the 6-month post-implementation completion rate increased to 83% (995/1194 patients), 90% (793/878 patients) and 99% (3101/3124 patients) (P 90% across all facilities. Conclusion: We demonstrate a successful, multifaceted, quality-improvement intervention centered on a clinic-level VLC which, taken to scale, has important implications for attaining the third UNAIDS 90-90-90 target.

This study described psychotropic prescription patterns among adults referred to a psychiatric outpatient clinic for individuals with intellectual disability and determined demographic, clinical, and organization-level predictors of receipt of three or more psychotropic medications concurrently (psychotropic polypharmacy).To identify predictors of psychotropic polypharmacy, a retrospective chart audit was conducted for patients with intellectual disability referred (N=517) to a specialized psychiatric outpatient clinic between 2005 and 2013.Seventy percent of patients were prescribed at least one psychotropic medication, and 22% received psychotropic polypharmacy. Women, those living in supervised residential settings, and those with a psychiatric diagnosis in two or more diagnostic categories were more likely to receive psychotropic polypharmacy.Polypharmacy is a significant concern for adults with intellectual disability seeking specialized psychiatric services, with multiple contributors to prescribing practices. Both psychiatrists and family physicians can play a role in the judicious use of medications for this vulnerable population.

Background Most caries prevalence studies are conducted in community-based settings, usually with no radiographs, therefore, it is questionable if visual examination alone captures the true extent of disease. Aim Since it is relatively easy to diagnose occlusal and facial/lingual surface (nonproximal caries) on visual examination, our aim was to evaluate for an association between nonproximal caries (NP) and proximal caries (P), which if present can provide a tool to help decision makers in estimating the true extent of the disease. Design A cross-sectional retrospective chart audit was done using records of 106 children to determine the association between NP and P caries in the primary dentition. Results Our mean dft for NP lesions only was 1.55. Based on our data, the mean dft considering all pit and fissure plus the proximal lesions was 2.54, which is a 63.2% increase from the dft based on NP caries only. We found a significant association between NP caries and radiographically detectable P caries. Proximal lesions were twice as likely to exist on primary molars when non-proximal/pit and fissure carious lesions were present. Conclusion The results imply that proximal caries, and thus need for treatment, are being underestimated during visual exams. How to cite this article Dhar V, Mon S, Macek MD. Evaluation of Nonproximal Caries as Predictor of Proximal Caries in Primary Molars. Int J Clin Pediatr Dent, 2018;11(6):457-461.

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: We retrospectively investigated COVID-19 patients on anticoagulation or antiplatelet medications as their home medication or used as inpatient treatment to evaluate if they exhibited lower levels of D-dimer and lower rates of embolic events and mortality. METHODS: This correlational retrospective study evaluated n=319 COVID-19 patients admitted to acute inpatient services across the Mercy Health Youngstown hospitals. A retrospective chart audit included home medications and admission medications, hospital and ICU length of stay, days on the ventilator, initial and follow-up labs (D-dimer), and thromboembolic events after diagnosis of COVID-19. We constructed a composite index for any embolic events occurring in inpatient: MI, DVT, PE, stroke, and cardiac arrest. The prevalence of these embolic events was 23.5% (n=75/319). For propensity modeling, comorbidities, initial D-dimer, demographics, days from a positive COVID-19 test result to admission, and a summative index of comorbidities were entered in a binary logistic regression model to predict embolic events. RESULTS: The rate of any embolic events among COVID inpatients was 23.5% (n=75/319). Initial D-dimer was 1648±1702 ng/mL among patients experiencing any embolic events and was lower among patients without embolic events, 1009±1205 ng/mL (t=3.638, p < 0.001). In iterative forward selection, logistic modeling retained in the model for embolic events were age, initial D-dimer, past medical history of ESRD, and ethnicity, which correctly classified 75% of embolic events in patients (AUC=0.702). The addition of home medications, antiplatelets and anticoagulants to the propensity model did not significantly improve AUC (0.704) which indicates that neither home use of anticoagulation nor antiplatelets was associated with inpatient embolic events in a propensity adjusted model. However, when inpatient anticoagulation therapy was initiated, statistically significant benefit in preventing embolic events was observed (AOR = 3.32 (95% CI 1.79-6.16);AUC 0.752 (p < 0.001)). Similarly, home use of antiplatelet and anticoagulation medications was not associated with mortality in COVID-19 patients, but in-hospital use of anticoagulation was statistically significant (p=0.036). CONCLUSIONS: Our study aimed to see if taking antiplatelet or anticoagulation medications as a home medication would have any effect on thromboembolic events and mortality in COVID-19 patients compared to when receiving antiplatelet or anticoagulation agents during hospitalization. We found that being on an antiplatelet or anticoagulation medication at home (before hospitalization) did not prevent COVID-19 patients from thromboembolic events or improve mortality. However, after adjusting for baseline risk of embolic events, in-hospital anticoagulation had a statistically significant benefit in preventing embolic events and mortality. CLINICAL IMPLICATIONS: It has been established that COVID-19 patients are at higher risk for embolic events that have been linked to increased mortality. In our current study using a composite index model to predict embolic events in COVID-19 patients, the use of anticoagulation agents during hospitalization revealed a significant reduction in embolic risks and mortality while patients on home antiplatelet or anticoagulation medications did not show benefits in reducing the same risks. DISCLOSURES: No relevant relationships by Omotooke Babalola, source=Web Response No relevant relationships by Timothy Barreiro, source=Web Response No relevant relationships by David Gemmel, source=Web Response No relevant relationships by Oyidiya Osoka, source=Web Response No relevant relationships by Jeannie Ur, source=Web Response

Pneumococcal disease is a healthcare concern with increasing financial and societal burden for adults over the age of 65 years and their caretakers. The Center for Disease Control and Prevention (CDC) recommends the use of pneumococcal vaccines in this population as a preventive measure helping minimize the mortality and morbidity. This project aimed at increasing the rate of pneumococcal vaccines in a Federally Qualified Health Center (FQHC). The interventions implemented included the use of audit, feedback and provider educational intervention aimed at increasing the knowledge and the intent to change and improve their practice. The key results indicated an increase in aggregate pneumococcal vaccines in the organization as well as an increase in individual and historical vaccination rates for the organization and individual providers. The implications for practice include the improvement in vaccination rates significantly impacting the health of the community, as well as an increase in education provided regarding vaccination. The questionnaire provided positive feedback on the intervention. Further research to determine vaccination availability and re-vaccination should be considered.

Background Australians living in regional, rural, and remote areas face a myriad of complexities resulting in a trend to poorer health outcomes. Telehealth is being utilised as an alternative mode of service delivery to overcome such barriers. However, there is limited published information concerning the use of telehealth in perioperative medicine. Aims The purpose of this study was to review the performance of the telehealth pre-operative assessment service at Mater Hospital Brisbane to determine last-minute cancellation rates secondary to medical reasons. Methods A retrospective chart audit of all patients referred to perioperative medicine telehealth consultation services provided at Mater Hospital Brisbane. Results During a one-year period, 229 patients across 8 surgical subspecialties were referred for telehealth assessment (85 females, 144 males) with a median age of 67 years. Patients lived a median distance of 1597 kilometers from Brisbane. Of the 229 patients included in the study, 7 (3.1%) experienced last-minute cancellations. From this data, the last-minute cancellation rate due to medical reasons was 1.3%, which is consistent with the international average. Conclusion The Mater Hospital Perioperative Medicine telehealth Program is a means of providing comprehensive perioperative assessment to regional, rural and remote patients that result in reduced last-minute surgical cancellations and surgery within or below the national recommended guidelines.

Introduction: Advance care planning (ACP) is a patient-centered process with clear benefits for patients. Despite the widespread recognition of ACP as an integral part of quality cancer care,compliance with ACP provision remains suboptimal especially in malignant hematology. Many barriers to end-of-life discussions among hematologists have been identified in the literature. This study aims to describe a baseline rate of ACP with hematology outpatients at the end-of-life and the local barriers to ACP, which could inform future quality improvement (QI) initiatives in this area. Setting/participants: Malignant hematologists (n = 10), hematology fellows (n=2), and hematology clinic nurses (n=4) of the Juravinski Cancer Centre (JCC) in Hamilton, Ontario, Canada participated in this study. Methods: A retrospective chart audit was undertaken to establish the baseline rate of ACP for the target population at our centre. Subsequently, key stakeholder interviews were held with our local multiple myeloma (MM) specialists to document barriers to ACP from their perspectives. The emerging themes were synthesized using a Fishbone diagram and validated by the JCC hematology clinic staff through multivoting. Results: The baseline rate of ACP with hematology outpatients at the end-of-life at our centre is 40%. The are three main local barriers to ACP with the target population: 1) lack of patient initiative; 2) time/scheduling constraints; and 3) competing priorities. Discussion: Patients who participate in ACP are much more likely to have their end-of-life wishes followed than those who do not. Malignant hematology patients are at the greatest risk of not having ACP discussions with their clinicians due to several patient, provider, and system barriers. Patient- and system-level barriers have been identified as the most prevalent at the JCC, necessitating a tailored QI initiative to achieve the standard of care. Disclosures Hillis: Roche: Honoraria.

Introduction: Choosing Wisely Nova Scotia (CWNS), an affiliate of Choosing Wisely Canada™ (CWC), aims to address unnecessary care and testing through literature-informed lists developed by various disciplines. CWC has identified unnecessary head CTs among the top five interventions to question in the Emergency Department (ED). Zyluk (2015) determined the Canadian CT Head Rule (CCHR) as the most effective clinical decision rule in adults with minor head injuries. To better understand the current status of CCHR use in Nova Scotia, we conducted a retrospective audit of patient charts at the Charles V. Keating Emergency and Trauma Center, in Halifax, Nova Scotia. Methods: Our mixed methods design included a literature review, retrospective chart audit, and a qualitative audit-feedback component with participating physicians. The chart audit applied the guidelines for adherence to the CCHR and reported on the level of compliance within the ED. Analysis of qualitative data is included here, in parallel with in-depth to contextualize findings from the audit. Results: 302 charts of patients having presented to the surveyed site were retrospectively reviewed. Of the 37 cases where a CT head was indicated as per the CCHR, a CT was ordered 32 (86.5%) times. Of the 176 cases where a CT head was not indicated, a CT was not ordered 155 (88.1%) times. Therefore, the CCHR was followed in 187 (87.8%) of the total 213 cases where the CCHR should be applied. Conclusion: Our study reveals adherence to the CCHR in 87.8% of cases at this ED. Identifying contextual factors that facilitate or hinder the application of CCHR in practice is critical for reducing unnecessary CTs. This work has been presented to the physician group to gain physician engagement and to elucidate enablers and barriers to guideline adherence. In light of the frequency of CT heads ordered EDs, even a small reduction would be impactful.

Background: The majority of individuals who have had a mild stroke are discharged home from acute care. Yet, the proportion who are assessed for driving ability and given related recommendations is unknown. Objective: To describe acute care practice related to driving among individuals whose discharge location is home. Methods: A secondary analysis of data from a chart audit was realized in the Province of Quebec, Canada. Data were retrieved from the charts by trained extractors. Evaluation practice was described according to whether the driving assessment was specific or nonspecific to driving (cognitive, perceptual and visual functions). Descriptive statistics were used. Results: The sample consisted of 419 charts of individuals with a mean age of 70.5 ± 13.3 years old. Mean length of hospital stay was 10.3 ± 13.3 days. Specific driving assessment was documented among 26/419 (6.2%) charts while for seven of these, the assessment was considered full. Meanwhile, 92/419 (22.0%) were considered as problematic for driving a vehicle. Nonspecific driving assessment was documented among 70/419 (16.7%), 43/419 (10.3%) and 33/419 (7.9%) of charts for cognitive, perceptual and visual functions, respectively. Charts were characterized by several missing data relating to driving. Conclusion: The proportion of charts documenting driving restriction post-stroke in acute care was very low. Assuming that all driving discussions and referrals were captured in the charts (which may not be the case), our results would indicate an important gap in acute care practice as compared to best practices relating to driving post-stroke.

BackgroundOral dextrose gel is an evidence-based treatment that has been shown to reduce NICU admissions and support exclusive breastfeeding.PurposeWe summarize a knowledge translation project to introduce dextrose 40 percent oral gel to treat hypoglycemia or hyperglycemia. Implementation took place during the months of May, June, and July 2017.ResultsThrough chart audit, rates for NICU admissions and exclusive breastfeeding were measured for a three-month period before implementation and the three-month period after implementation.There were 234 doses indicated, 128 doses given, 93 doses missed, and 13 doses declined by parents in the first three months of implementation. Admission rates to the NICU for the groups audited were 13 percent in 2016 and 6 percent in 2017.Principles of knowledge translation were used to successfully introduce this change. Centers providing maternal newborn care should consider similar projects to enable introduction.